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Aesthetics Practice Today

Advanced Eyebrow Tattooing
July 21, 2015 9:47 AM by Mina Grasso
The new buzz in advanced permanent eyebrows is modern microblading micropigmentation also known as 3D Eyebrows, Eyebrow Embroidery or Feathering. Microblading is one of the oldest techniques used for cosmetic tattooing. In the last few years advanced modern tools have been developed making this technique a very sought after procedure that promotes a natural appearance.    A small pencil-shaped hand instrument with disposable microblades comprised of microneedles is used. The microblading technique it a much more refined technique using much finer needles than tradition micropigmentation needles that have been used for decades. The quantity of needles and the blade types can vary. 

The microblading micropigmentation hand instrument is used to delicately apply pigment as fine hair strokes with more definition and dimension resulting in the most natural-looking realistic soft eyebrows that can enhance a patient's natural features. Many patients are still afraid of getting their eyebrows tattooed largely as a result of people they know who have had cosmetic tattooing especially of the eyebrows that either had poor color selection but most often size, shape and the solid look of the tattooed eyebrows have dominated their faces. 

As with tradition cosmetic micropigmentation, the eyebrow color will appear much darker the first week. After the scab formation peels, the resulting color is closer to the end resulting color. This technique should enhance color retention longer than tradition methods. The color should last about 1-2 years.

Microblading is becoming a very popular technique for cosmetic micropigmentation of eyebrows in various parts of the world including Asia, Europe and the US.  Patients are seeking information on this exciting new technique from their hair stylists, cosmetic consultants and plastic surgeons. They are all seeking a natural soft appearance of eyebrows that can enhance their natural beauty that modern microblading can offer.

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Stretch Mark Therapies
July 7, 2015 12:29 PM by Mina Grasso

Stretch marks can be found on various parts of the body including the abdomen, thighs, hips, breasts, and arms, behind the knees, flanks and low back. Both men and women at different ages can develop these stretch marks.

Stretch marks can present differently depending on the skin type. They can range in color from white, silvery, pink, red, reddish purple to dark brown. Stretch marks usually appear more pink and red in the early stages and as time goes by, they become more white or silvery and appear indented.

It was felt that rapid stretch of the skin alone was the cause of stretch marks. It is now believed that an increase in cortisone, a hormone produced by the adrenal glands, contributes to the development of these unsightly parallel linear patterns. Elastic fibers in the skin may be weakened by cortisone. Genetic factors may also play a role. The physical stretching of the skin and hormonal factors play a role in the development of stretch-marks in pregnant women, teenagers during a growth spurt, body builders with substantial weight gain, use of corticosteroid creams or systemic steroids as well as those with various disease processes that affect the adrenal glands.

Over the years people have spent hundreds of dollars on useless lotions and potions that claim to make stretch marks disappear. Limited data is available for topical solutions that improve stretch marks. Tretinoin (Retin-A) has been shown to improve the appearance of stretch marks when used in the early stages. It works by stimulating collagen production. However, skin can become very irritated and patients need careful guidance on proper use of this product. Unfortunately it cannot be used during pregnancy.

Although nothing has proven to eliminate stretch marks, there are various lasers and light energy that can improve the appearance. Early treatment yields better results. Intense pulsed light (IPL) and V-Beam, a pulse dye laser can reduce the red appearance of the stretch marks. Fractional laser resurfacing vaporizes away a fraction of the scarred tissue and is replaced with new growth of collagen and elastin resulting in renewed skin with improved texture and color.

A device called Viora Reaction, utilizing bipolar radiofrequency, has surprised us unexpectedly in improving the appearance of stretch marks. In our clinic, we use this device for cellulite and skin tightening, and have seen improvement in stretch marks in the areas that we have treated. So far we have not had patients report hypo or hyperpigmentation. Response to treatment will vary among individuals. 

Microneedling using the Dermapen has been a procedure that has yielded results beyond expectations. Different for the more traumatic dermal rolling, Dermapen utilizes groups of fine needles with adjustable depth of penetration depending on the condition to be treated. Collagen and elastin is stimulated by the microneedling to improve the appearance and texture of the skin. In addition, platelet rich plasma (PRP) can be applied topically immediately after the micro-channels are created, enhancing penetration of the PRP. This turns on the body's own regenerative process to repair the tissue being treated.

Realistic expectations need to be set. Results may vary depending on the severity of the stretch marks and the number of treatments. In many cases, a combination of modalities can yield the best results. These treatment modalities are costly and multiple treatments are usually required over a period of time. I tell all patients that stretch mark treatment is never 100%. Although these modalities can improve the appearance of the stretch marks, residual evidence of stretch marks may remain.

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Restylane Silk: Smooth and Natural Enhancement
June 23, 2015 2:08 PM by Mina Grasso
The "liquid facelift" has been an innovative answer to the demand for a rapid non-surgical way to enhance and rejuvenate the youthful volume that has diminished with aging. Over the last decade this has been accomplished with various fillers, neuromodulators like Botox and biostimulators that encourage growth of one's own skin components.

The "liquid facelift" has allowed us to understand and teach our patients about the natural aging changes of the face that relates to volume loss from diminished fat, muscle and unfortunately even bone as well as thinner skin. As a result of an increased understanding of facial aging, we have changed the manner in which we approach facial rejuvenation with volume. New products such as Voluma have entered the market to help us approach our patients differently in order to restore a more natural youthful appearance. Often diminished deep fat pads can be supplemented to approximate an appearance one had in the picture we carry of ourselves in our mind. We have come a long way since the days of superficially placed bovine collagen that lasted around three months to products that can last up to two years. We have moved away from chasing lines to global volume replacement from forehead to chin.

Although tissue fillers have been around over decades, many patients are still hesitant and fear looking unnatural and overdone. Over the years they have witnessed others who appeared "ducky", "monkey-like," "puffy" or "too full."

One of the biggest "giveaways" that many have witnessed is a mature woman with vertical lip lines that have been over filled with Juvederm or Restylane and distorted the shape of the upper lip in particular creating a "Marge Simpson" look with the upper lip protruding much past the lower lip. Patient's facial structures and ideal shapes are very different. The goal is to understand the volume change for each individual that is enhancing and flattering and often will not be detected by an observer as "having some work done."

Restylane Silk is now available to address the challenges that we have had with other fillers. Patients are sometimes not interested in getting fuller lips but simply want to address the vertical lip lines. In certain instances this will be all that needs to be done. In addition, patients who have lost definition of the lips due to the natural process of aging, environmental factors and habits can benefit with subtle enhancement-like lip definition. I often recommend patients a more "hydrated" appearance of their lips with Restylane Silk as the product, hyaluronic acid, will indeed hold more water in the area like a younger person does with the higher natural hyaluronic acid concentration in their skin.

Various fine lines around the face including the crows feet, glabella, forehead, nasal labial and cheek creases are ideal areas for Restylane Silk. Another one of my favorite areas to treat with Restylane Silk is along the infraorbital to the lateral orbital area that is below the eye over to the hairline area, often thin, crepey and sometimes showing fine lines of volume depletion. Some women have very thin skin overlying the bony structures and many of the other fillers have a higher risk of lumpiness and can cause a Tyndall effect, or bluish look where the filler is visible through the thin skin.

Restylane Silk is used much like bovine collagen fillers in the past to address vertical lip lines, lip reshaping and mild enhancement as well as fine lines in various fine lines around the face. Restylane Silk's advantage is it lasts about double the duration depending on the patients skin status and location of product placement. 

It seems that we have gone full circle with availability of tissue fillers. Our focus went from chasing lines to plumping, volumizing and lifting and then back to the old way, filling lines softly and naturally in order to address needs of patients whose concerns are fines lines around the lips and face, lip reshaping and subtle enhancement.

When using the Restylane Silk to primarily address superficial fine lines one to two syringes can cover a lot of ground.  Adding Restylane Silk can be the ultimate. finishing touch to a revolumized and contoured rejuvenated face.

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A New Solution for Double Chins
June 9, 2015 10:22 AM by Mina Grasso
Men and women often complain of disliking their profile due to their undesirable "double chin" or fullness of their neck due to submental and submandibular fat deposits under the chin or jawline. This condition is usually associated with genetics, aging and/or weight gain. It may be seen in patients within their ideal weight. The appearance of neck convexity or fullness negatively impacts these individuals, and they are often perceived as heavy or older.

Many patients assume that surgery is the only option. Now, these unmet needs can be addressed using a non-surgical option with injections to destroy fat cells. Injection of deoxycholic acid into the submental fat causes a denaturation of the fat deposits and dissolves the fat ,which allows the body to absorb it. This results in non-surgical contouring and sculpting of the neck. It is a procedure that we along with many other clinics have performed with variable results using deoxycholic acid compounded from various pharmacies.

Deoxycholic acid is produced in the body and helps the body absorb fats. Deoxycholic acid is a cytolytic drug. When it is injected into fat cells, it destroys the cell membranes. Practitioners must be properly trained to inject deoxycholic acid.  Accidental injection into surrounding tissue can cause destruction of those cells as well for instance surrounding muscle and nerve cells.

Deoxycholic acid will now be available for the first time as an FDA approved submental contouring injectable drug called Kybella. Kybella has undergone clinical studies for safety and effectiveness. Over 20 clinical trials with more than 1600 patients treated yielded high patient satisfaction. The anticipated arrival will be later this month. Kybella is the first and only approved non-surgical treatment for reduction of submental fullness or convexity. 

An ideal candidate for the treatment of the "double chin" with Kybella is a patient within their ideal weight with fullness of the neck, which is resistant to diet and exercise. Practitioners can customize the number of treatments to their patients according to the amount of submental fat. Most patients will require 2-6 treatments.  After desired reduction, patients usually will not require re-treatment. An anticipated concern may be residual skin laxity, but the inflammation caused by the Kybella may cause variable degrees of tightening, so a secondary tightening procedure may not be required after the series of injections.

The injections elicit minimal pain response, but due to inflammatory changes of the fat cells initial swelling post-injection can be expected and may last approximately 2-5 days, so some down time may be expected. Other adverse reactions may include  bruising, pain, numbness, erythema or formation of small areas of firmness at or around the injection site. Also the area may remain slightly more sensitive to touch for several weeks. Most of the adverse reactions were reported to be mild.

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Décolleté’/Cleavage Rejuvenation
May 26, 2015 10:15 AM by Mina Grasso
Warm weather brings out more revealing outfits that show off arms, the décolleté/cleavage, back, legs and midriffs. Patients are becoming more aware of sun protection, skin care and anti-aging measures for the face, but many times stop there. The chest or décolleté/cleavage accumulates sun damage over a lifetime, and blotchy mottling, discoloration with brown spots, redness, veins, skin texture irregularities, fine lines and wrinkles develop. With the loss of collagen and elasticity as we age and accelerated with sun exposure, our body positioning such as when sleeping can contribute to the formation of certain creases and lines in the décolleté. 

Tank tops and revealing necklines can still be enjoyed using some anti-aging, rejuvenating measures. It's important to avoid or minimize further damage using sun protection. Skin care utilizing SPF and a combination of retinoids, bleaching agents, vitamin C, green tea, alpha hydroxyl acids, peptides and growth factors on a regular basis has been proven to improve skin quality and reverse signs of sun damage.

Many aesthetic treatments have also been beneficial in treating sun damage including but not limited to microdermabrasion, chemical peels, microneedling alone or with platelet rich plasma (PRP) to regenerate more youthful collagen using the patient's own growth factors to stimulate repair.

Light and laser devices are commonly used. Intense pulsed light (IPL) or Photorejuvenation can treat sun damage targeting red and brown discoloration as well as texture. Patients who have received a series of treatments have been reported to show more youthful gene patterns by skin biopsy. More stubborn pigmentation can be reduced with lasers that specifically target pigmented lesions. Ablative laser resurfacing such as fractional CO2 laser can effectively improve the texture of the skin by removing damaged skin and stimulating growth of new collagen in the cells and improving elasticity

Neuromodulators such as Botox and Dysport is a popular request for improving the appearance of lines and wrinkles as well as use of fillers such as hyaluronic acids to fill deeper lines and wrinkles. I have used bioactivators such as Sculptra (PLLA) to plump and improve skin quality by stimulating the patient's own collagen.

Patients desire skin tightening. The modalities we have used were primarily non-invasive radiofrequency. These non-invasive no-downtime include monopolar radiofrequency such Thermage or bipolar radiofrequency such as Viora Reaction. The radiofrequency is delivered to the surface of the skin, stimulates tissue contraction and new collagen growth resulting in tightening of the skin gradually over time without limitation of the patient's activity. The future looks promising for use of injectable RF such as ThermiTight RF for minimally invasive skin tightening of the décolleté and lifting of breast tissue without incisions.

Multiple treatments may be required depending on the age of the patient when starting treatment, skin type, hormonal status, skin condition, sun habits, therapeutic and maintenance skin care and follow-up treatments. Patients can look forward to reduction of some of the sun damage that has accumulated over the years and be able enjoy younger more vibrant looking skin in their tank tops and revealing necklines.
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Non-surgical Facial Enhancement of the Upper Face
May 12, 2015 11:39 AM by Mina Grasso
Beauty of the upper face can be enhanced significantly using non-surgical techniques with neuromodulators and tissue fillers. Since the FDA approval of Botox for frown lines over a decade ago, patients have been well aware of the benefits of neuromodulators to improve the appearance of frown lines, crows feet and horizontal forehead lines. Typically patients think primarily of using neuromodulators to enhance the forehead but are not very aware of the benefits of adding volume to the forehead.  

When patients are first treated with neuromodulators, they experience a "wow" with the results. As the natural process of aging takes place, loss of collagen and elasticity as well as loss of volume of the upper face requires the addition of tissue fillers to not only reduce the appearance of wrinkles but to return volume and shape to the area.

Patients are familiar with tissue fillers in the nasal labial folds due to the ads and brochures that circulate with images of the "parentheses. Since Sculptra, a collagen activator and now the newest hyaluronic acid, Voluma, was introduced, awareness in a more global approach to the face is increasing in popularity. An area that had been limited to neuromodulators for most practitioners is the forehead.  Volume loss contributes a great deal to the loss of the "golden" proportions and shape to the forehead. When the forehead is rejuvenated and volume is replaced, a more youthful, well-rested face with natural appearing transitions is the outcome.

When patients start to express concerns of neuromodulators not working as well as they used to, especially in the upper face and around the eyes, it becomes important to evaluate volume loss in these areas.  Frequently patients report that these areas are their last concerns, because their hair covers their temples and their bangs usually can cover their foreheads. Patients who have experienced ptosis of their eyelids who avoid neuromodulators in the forehead are more open to discussing this option. 

A clear understanding of ideal shape and proportions of male and female genders and the concept of global facial rejuvenation in critical in educating the patient on how we can help them to look more refreshed, youthful and natural safely. When we understand what the ideal proportions of beauty, we can reflate and contour the face and deliver optimal results. Tissue fillers can treat glabellar or horizontal creases, temporal hollows, enhance eyebrow and forehead re-shaping.

As a practitioner, understanding the anatomy of the face with respect to critical structures such as facial arteries, veins and nerves is important and enhances our confidence in providing a safe treatment minimizing pain and bruising. The experience for the patient is equally important as the outcome of results.
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ThermiVa
April 28, 2015 9:04 AM by Mina Grasso
For several months, we have been offering a minimally invasive skin tightening procedure called ThermiTight injectable RF that allows us to tighten skin of the jowls and neck, upper arms, abdomen, knees and thighs. This device uses the ThermiRF radiofrequency platform for various applications with unique real-time precise thermoster controlled mircro-invasive and non-invasive treatments.

The most recent application is called ThermiVa. ThermiVa was introduced at the IMCAS World Conference as a breakthrough in non-surgical vaginal rejuvenation.

Years ago we offered laser vaginal rejuvenation in our clinic by OB/GYNs specialized in performing the procedure, creating a more aesthetic appearance, but it required surgery and involved downtime. The procedure is still performed today, but if given an option, most women would prefer a non-surgical approach without downtime.

ThermiVa requires a specific vulvovaginal radiofrequency applicator to work with the ThermiRF platform. ThermiVa is completely performed non-surgically and requires no anesthesia. There is no downtime required after the procedure. Gentle gradual heating allows the patient to tolerate therapeutic temperatures that stimulate collagen contraction and therefore skin tightening resulting in vulvovaginal rejuvenation. It's like performing a vulvovaginal "face lift" without surgery in an aesthetic clinic.

Vulvovaginal laxity, dryness, tissue stretching, nerve impairment, incontinence due to aging and loss of collagen are common issues that many women learn to live with and are often not discussed. Some women never even bring up these issues to their gynecologist thinking that nothing could be done anyway. Unfortunately, any one of these issues can make a woman feel less attractive, reduce her sense of well-being, impede sexual satisfaction and interfere with intimacy.

Red Alinsod, MD, FACOG, FACS, ACGE, a global leader of temperature controlled RF in vulvovaginal laxity, presented the findings of a pilot study using the ThermiVa procedure to treat vulvovaginal tissue using temperature controlled radio frequency. Alinsod is the Chairman of the ThermiGyn Women's Health Advisory Clinical Board.

Alinsod's study results showed both vulvar laxity and vaginal laxity improved significantly for all patients after the first treatment and continued to improve after the third and final treatment. In addition, participants reported improvement in sexual satisfaction, vulvovaginal tightening as well as improved vaginal moisture and improved continence as a result of the treatment.  Dr. Alinsod noted, "The potential for a simple and safe temperature controlled RF device to treat vulvovaginal laxity, atrophic vaginitis, mild to moderate stress incontinence, overactive bladder, and orgasmic dysfunctions holds great promise and could be transformational.

The aging process affecting the vulvovaginal skin treated with a non-invasive method can now be provided as a simple no downtime office procedure to those seeking aesthetic enhancements and may provide improvement in sexual enhancement and sense of well-being.

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Smoother, Tighter Skin without Downtime
April 14, 2015 11:18 AM by Mina Grasso

Over the last decade we have seen a tremendous growth in the development of non-invasive, non-surgical devices that promote skin tightening. The latest addition to our armamentarium of rejuvenation includes the ThermiSmooth procedure, which utilizes external radiofrequency energy for gentle, precise epidermal heating. It’s the only system that the temperature can be adjusted for the specific area of concern.

When the skin temperature is sustained to approximately 40°-42°C, an inflammatory response is created and stimulates the fibroblasts in the tissue to produce collagen. The heat stimulates collagen contraction that results in tighter, smoother skin over time. A precise amount of heat is required while appropriate technique is used to maintain the temperature for 5-7 minutes over a small zone. Multiple zones such as the forehead, around the eyes, cheeks, around the mouth, jowls and neck can be treated. 

The most popular area requested is around the eyes. This is an area that usually reveals our age, and there are not a lot of treatment options that address the skin quality under the eyes and eyelids without downtime.   This is an option for patients who cannot afford the downtime of a more aggressive ablative fractional CO2 laser resurfacing treatment. “Social downtime” is many times the reason for patients to avoid certain treatments. Now we have ThermiSmooth, which can be performed within a few minutes, and normal activities can be resumed immediately. Patients can even be treated during their lunch break.

During the ThermiSmooth procedure, a gel is applied to the skin. The hand piece is usually moved in a circular motion over the gel until the target temperature that is set (usually 42°C) is reached, and then a faster gentle sweeping motion is applied to sustain the temperature while keeping the patient comfortable. Sustaining the temperature for 5-7 minutes is key to the collagen stimulation. 

Four to six treatments two weeks apart are usually recommended depending on the patient’s desired results. Although some improvement may be seen immediately after treatment, continued improvement in skin thickness and skin quality is observed over several months after the ThermiSmooth sessions. 

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Life Changing Fractional CO2 Scar Revision
March 31, 2015 9:29 AM by Mina Grasso
Laser skin treatments goes beyond rejuvenation, photoaging and wrinkles. Lasers can play an important role in scar revision. Scars can form anywhere on the body as a result of trauma, burns, surgery, cystic acne or some genetic predisposition such as spontaneous keloid formation. 

Until the development of Fractional CO2, we were limited to pulse dye lasers to treat vascular and/or pigmented lesions or a variety of non-ablative lasers. These lasers help to improve the appearance of scars and are still today used in combination with fractional CO2 lasers. Different lasers and wavelengths cause different wound-healing responses. Non-ablative lasers provide lasers focus on heating the skin to trick body to sense that it has been injured stimulating a healing response, while ablative lasers actually removes some of the tissue causing a wound and allows the body to heal and form normal tissue. Fractional CO2 lasers are considered ablative as compared non-ablative lasers. 

Adding the fractional CO2 laser to scar reduction has significantly enhanced the degree of improvement with fewer treatments as mentioned by Geronemus RG in Laser Surgery Medicine Journal 2008.

The fractional CO2 laser can penetrate thickened, non-flexible scar tissue, remove it and allow new tissue to form. Treatment has improved range of motion especially in burn scars. Therefore, scar revision in burn survivors not only improves the appearance of scars but improves functionality. Usually each treatment improves the scar. All skin types can be treated as long as appropriate parameters are used for the different skin types. Old and new scars can be treated.

Dr. Jill Waibel, who recently presented webinar sponsored by Lutronics, spoke on the Lutronics fractional eCO2 laser March 2015 and tissue repair on all types of scars is creating more awareness of reducing physically and emotionally disabling scars. She feels that there are many more scars that can be treated, and patients are not aware of the possibilities unless resources are brought to their attention. Due to modern medicine, many more are surviving burns and other traumatic injuries so there are many more scars to be treated.

Dr. Waibel feels early intervention is crucial. In the past we have been programmed to wait until the scar is more mature, but with early intervention, fractional laser co2 can actually prevent the more fibrous tissue formation. This concept can apply to most types of scars.

With increased awareness of the life changing benefits of scar remodeling with fractional CO2 laser resurfacing, more patients can be helped to lead more normal lives, improving physical function in every day home life or the work environment as well as improve their emotional well-being.

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Ear Lobe Rejuvenation
March 17, 2015 7:49 AM by Mina Grasso

Women wear earrings over many decades. Various sizes, shapes and colors are coordinated with trends in fashionable wear throughout the seasons. When heavy earrings are worn repeatedly for long periods of time, the weight of the earrings can distort and elongate the opening of the pierced lobe. An obvious tear of the lobe may prompt a patient to seek treatment to repair the tear, but most are not aware of other ways to rejuvenate and reverse the appearance of aging that occurs.

As we become more advanced in understanding the concepts of facial aging and volume loss, we learn to venture into new areas of facial rejuvenation. Area patients rarely ask about or mention that we can and should introduce to the patient is rejuvenation of the ear lobes. This is especially important when we discuss pan facial rejuvenation with the goal to help the patient appear more balanced as we attempt to transition one area of the face to another smoothly.

During the assessment of the patient who is volume depleted, you will probably notice wrinkles pre-auricular and you may notice that the patient's earrings are tilted and pointing downward rather than forward. If you ask the patients to remove their earring, you will probably see folds and shadows adjacent to areas of convexity.

A youthful jawline may look longer with the cartilage reflecting light, which continues under the cartilage. If you follow the cartilage to the end of the jawline you can draw a continuous line where as the shadow created by lost volume under the cartilage gives a shorter appearance of the jawline. It takes a small amount of product to fill this hollow under the cartilage, and a small amount of product injected into the earlobe can also make it look more youthful with wrinkles or folds smoother with less shadowing. Injecting a lot of product into this area is not desirable and can make patients ears appear like Dumbo. Volumizing the earlobe and the shadow below the cartilage creates a line of light from the earlobe to the jawline giving the patient a more youthful look.

Rejuvenation of the ear lobes and surrounding skin is an area that is usually introduced to the patient by the practitioner. It is rare for a patient to bring this up. Many times ear lobe rejuvenation needs to be pointed out to patients using a mirror or photographs. Patients are usually amazed after they see the before and after photos and appreciate that you made the recommendation.  

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Liquid Facelifts – Difference in Male versus Female
March 3, 2015 10:26 AM by Mina Grasso

There is more pressure today for men to look fashionable, fit and well groomed. Male grooming products in the beauty industry are fast growing. Men are more concerned with their appearance and spending more time and money on themselves than ever before. Photos in the social media world have added to this pressure for males.

There are an increasing number of males seeking noninvasive and minimally invasive cosmetic procedures with little downtime to no downtime over the past few years. A desire to appear more refreshed, youthful and competitive along with a growing social acceptability of cosmetic procedures and increased safety and efficacy are all factors that contribute to the increase in male patients seeking more of these procedures.

A liquid facelift, using a combination of neuromodulators and tissue fillers, is growing in popularity in males as well as females. Much care is needed in the assessment and goal setting for males undergoing a pan-facial liquid facelift. The goal is towards maintaining a natural masculine appearance with smooth transitions from the top of the forehead to the jawline. All measures must be taken not to feminize a male face. 

When discussing cosmetic procedures with a man, choosing words carefully avoids the fear of looking feminine. Men do not care to hear the word "beauty" and prefer masculine descriptions. They are comforted with words such as "well-rested" and "refreshed." They are less specific with details and simply want to look younger.

When using neuromodulators, dose needs to be adjusted to address muscle mass in the forehead, glabella and crows feet. On average, depending on the number of areas treated for the upper face, women may require 20-60 units whereas men may require 50-100 units. The male brow is more horizontal naturally while females prefer more arching of the brow. Men are not as obsessed with knocking out the crow's feet completely as women are.

The shape of the man's face is more squared or angular compared to a softer, heart-shaped female face. Bony structures and a more prominent brow are acceptable in males.  Men have thicker skin generally and deeper injection techniques provide a more natural skeletal support versus skin plumping. When using tissue fillers, features such as the cheeks must not be over accentuated. The preferred area for the apex of the cheek on men is usually infra lateral versus more lateral for a female. Avoid placing filler in the high lateral cheek or over the zygoma. When attempting to reduce the amount of facial hollow causing shadows, especially in an athlete, the goal is to reduce the hollows to make the person look healthier without looking puffy.

The temples in male are generally more convex than a female's, and may require more tissue filler. As men and women get older and the shape becomes more skeletonized, it creates an older appearance, and the shape of the head appears more like a peanut. Treatment of temporal hollows making the area more convex can create a more masculine appearance in males using a variety of tissue fillers. Females also require fillers in this area but feminine features allow for a bit more concavity.

Men require more volume in the chin and jawline for support and definition of the squared mandible for a stronger masculine look.

As we see male patients in our clinics seeking these minimally invasive liquid facelifts, the anatomy of the masculine face needs to be kept in mind. We need to provide a positive experience to meet the needs of the growing male population and help them to meet their goal of a more refreshed, well rested, healthy, younger-looking appearance.

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BellaFill For Acne Scars Can Be Life Changing
February 17, 2015 1:39 PM by Mina Grasso
Acne, the most common skin condition, can result in acne scars, in up to 95% of those who get acne. This disfiguring skin condition can be devastating and affect self-esteem and self-confidence. Just a few weeks ago, for the first time in history the FDA has approved a tissue filler for treatment of acne scars. BellaFill, formerly Artefill, provides long-lasting scar correction.  

Acne scars may present in a variety of ways. The technical names are boxcar acne scars, ice pick acne scars, rolling acne scars, hypertrophic and keloid scars. Patients can present with a combination of these types of scars. Acne scars are unattractive and difficult to conceal. Now patients do not have to "just live with it".

Treatment of acne scars also varies with the presentation of the scars.  The more challenging acne scars to treat are boxcar scars and ice pick scars. Boxcar scars have more defined edges that appear like a box. Ice pick scars appear as small pits or enlarged pores on the skin.

Hypertrophic and keloid scars are raised areas that are well defined or go beyond the boundary of the scar. Although a patient may present with a variety of these scars, Bellafill is indicated for the treatment of rolling scars. An average of two visits using a syringe at each visit is recommended four to eight weeks apart. Bellafill can be used for all skin types and all ages.

Bellafill is made up of 20% PMMA microspheres and 80% bovine collagen.  Correction is immediate. Bellafil helps to lift the scar to the level of the surrounding skin for a smoother appearance. As the bovine collagen dissipates the body's own collagen surrounds the PMMA matrix of microspheres and plumps the distensible rolling scars.

Results in the patient's self-esteem and confidence can change their lives. I had a patient come in for a follow-up appointment, and I was expecting to hear less than optimal satisfaction, because I could still see scarring. Getting back to realistic expectations that I prepared the patients for, I remembered that he had many ice pick and box scars which I had warned him would not respond like the rolling scars. Much to my surprise, the patient was ecstatic and could not express his appreciation enough.

Patients with depressed acne scars treated with Bellafil are often highly satisfied with long-lasting results especially if most of the scars are rolling and distendable scars without defined sharp borders.

Since the days of bovine collagen, more dermal fillers have been developed. There are a variety of hyaluronic acid fillers. The following are the most common: Belotero, Restylane, Perlane, Juvederm and Voluma.  These HA fillers vary in consistency and duration of action depending on the cross-linking of the molecular structure. The higher degree of cross-linking, the longer it takes the body to break it down. With the patient's own collagen surrounding the PMMA microsphere matrix of Bellafill, the results are longer lasting.

Artefill is a lasting dermal filler approved by the U.S. Food and Drug Administration in 2006 for the correction of the nasolabial folds commonly known as "smile lines." Artefill, now called Bellafil is the first FDA approved dermal filler to provide long-lasting correction of moderate to severe atrophic distensible acne scars. Finally, there is long-lasting hope. Patients do not have to "just live with the scars."
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Power Plate for Health, Fitness and Beauty
February 3, 2015 8:32 AM by Mina Grasso
Power Plate works using vibration technology where energy is transferred from the vibrating platform to the body. This mechanical stimulus produces a stretch reflex which, depending on the selected frequency, results in muscles vigorously contracting 30 to 60 times per second. Each vibration set is performed no longer than 30, 45, or 60 seconds in length.

Power Plate exercises increase the production of regenerative and repair hormones, strengthen bone tissue, improve lymphatic drainage and increase metabolic rate. All this results in more strength, speed and stamina, increased flexibility and controlled fat reduction. These exercises are a good remedy for osteoporosis, pain reduction, improves collagen production, reduces lower back pain and rehabilitates injuries and ailments. Athletes all over the world have experienced the benefits of the power plate in their rehabilitation programs.

Power Plate Advanced Vibration Technology is very popular in Europe, but is slowly gaining interest here in the US. On August 21, 2012 the University of Southern California celebrated its grand opening of the John McKay Center--a $70 million, 110,000-square-foot athletic and academic facility. Among its state-of-the-art athletic training and fitness equipment are six custom Power Plate pro7's. 

Our clinic has been offering Power Plate for over 11 years. Ten to twenty minute sessions twice a week is recommended with a primary focus on muscle toning. A great percentage of our patients who regularly use the device claim they are addicted and are amazed with the benefit of cellulite reduction. Just recently we started to offer Yoga in the room the Power Plate is located, but did not dare remove it in fear of the negative response from regular users. There is no scientific evidence that I am aware of, but personally, I feel patients are benefiting in reduction of skin laxity as well - probably due to some collagen stimulation.  I now have personal power plates both at home and at my vacation home.

First time users of the power plate are initially startled by the amount of vibration. The amount and length of time of vibration is adjustable. The learning curve is very short. Within a few minutes, patients learn exercises that will isolate the muscle groups they want to target.

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A Review of 10 Anti-Aging Secrets in the Last Decade
January 20, 2015 9:08 AM by Mina Grasso

Botox/Dysport: Neuro-modulaters Botox and Dysport have been around more than a decade and used prior to FDA approval for cosmetic purposes in some clinics. It became the WOW of the practice. By relaxing specific muscle groups, a person's muscle groups, they can appear happier and refreshed.

Tissue Fillers: Volume replacement has played a major role in helping one to look 10+ years younger. We have a better understanding of fat pad positioning in the bio-activators or a combination product and going beyond chasing lines such as the previous decade where collagen was introduced to a more global pan-facial approach keeping things looking more balanced and natural compared to years prior. Tissue fillers have made an amazing impact of non-surgical world of aesthetics.

Medical Skin Care: Advances in the delivery systems of skin care products has improved  therapeutic outcomes in acne, brown spots, redness and wrinkles etc. Patients can see and understand the transformation that occurs with compliance. More patients understand the importance of protecting their investment by using sun protection.

CO2 Fractional Laser Resurfacing: Fractional laser technology has allowed us to treat all skin types. With an appropriate skin prep and parameters for the skin type, patients can reduce wrinkles and result in overall more youthful skin. 

Photo Rejuvenation: One of the most popular non-ablative rejuvenation treatments involves photo rejuvenation - intense pulsed. Photo Rejuvenation treats redness, pigmentation, sun damage, acne, and pore size. Regular treatment have proven studies to show patients who have received a regular regimen of treatments show more youthful gene patterns when biopsies of skin treated non-treated skin was compared.

CoolSculpting - Freeze the Fat: CoolSculpting has changed the world of body contouring. For those seeking  non-surgical approach without downtime, CoolSculpting is a perfect alternative. Patients do best when near their ideal weight. With the right amount of cycles, patient can obtain near-liposuction results.

Radiofrequency Thermage, Thermitight RF: Thermage - monopolar radiofrequency was developed a little over a decade ago. Unlike much laser technology, we still provide this non-surgical skin tightening procedure for the face, neck and body. For those who want skin tightening without surgery and want to go beyond what Thermage can provide, ThermiTight RF is the in-between the "game changer" for the jowl   and neck area. It utilizes a thermal probe at the tip of the radiofrequency electrode while a FLIR camera is used to monitor the external temperature on the skin. With the accuracy of temperature guidance, consistency and safety aids in the popularity of this procedures with practitioners and patients.

Permanent Make Up: Permanent makeup has been performed many decades ago, but at the start of the decade, it was just starting to gain acceptance. When I first performed permanent makeup in 1997, people still felt somewhat reluctant to have it done due to seeing bad outcomes, taboo about a tattoo, and other various     reasons. Those who had the procedure enjoy waking up with makeup and love the convenience of saving time applying makeup. Colors, styles and techniques of application continue to improve over the years. Some patients report that it's the best investment that they have made.

Sclerotherapy: Sclerotherapy for unsightly leg and hand veins is the process of injecting solution to irritate and destroy veins and takes one to four weeks on average patients can dress in confidence again.

Bio-Identical Hormonal Replacement: Patients can now feel as good as they look with safer hormonal options. They can regain their motivation, energy, stamina and vitality and lead a more productive and happier quality of life. Vitality helps patients feel younger.

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Advances in Clinical Photography
January 6, 2015 8:23 AM by Mina Grasso

Patients frequently forget what they look like after aesthetic procedures. It is critical to have photos of patients before and after procedures for documentation to protect you and the patient. It is difficult to prove clinical improvement without proper imaging.

Over the years as more practitioners perform aesthetic procedures they appreciate the value of high quality professional photographs with user-friendly systems that are used for consultation, documentation and presentation. As a result, clinical photography has advanced tremendously. Aside from medical-legal issues photographs can be used for educating patients.

Standardization is the most important part of clinical photography. This includes the use of the same camera settings, background, lighting, positioning and expression of patient.  Attempts to have the same garment and avoiding jewelry such as earrings can assist in ease of evaluation. It is becoming well understood that just changing the lighting alone can create an amazing before and after photo.

Over the years, we have had various types of photography set-ups going from face to body. Many requests of patients to see before and afters left us a bit embarrassed to the following reasons: lack of photos, different positions and animation, different lighting, different clothing or objects obscure visibility including hair, jewelry makeup or eyeglasses.

After purchasing new equipment and having to incorporate body photography, we decided to abandon other systems after learning the benefits of guided user-friendly photography. Clinical photography for what we desired and what images were actually captured was always a challenge with staff. FotoFinder has developed onscreen templates that make it easy for staff to remember what photos and positions we are looking for with a specific procedure so that images are repeatable. If a new position is required, the image position can be input by the company. Retrieval of photos is easy and labeled by color "before treatment" vs. an "after treatment" with same positions placed side by side for comparison. In addition, the zoom lock feature can be used to compare the same exact spot to aid in comparison.

Using photos as a teaching tool was much more time consuming in the past and would obstruct the flow of traffic in the clinic when a patient had to be taken to the photo suite to review photos. Now, the FotoFinder iPad app provides image access in any of our consultation rooms immediately. Additional photos can be taken in the consultation room that can be stored and tagged for each particular procedure and goes directly into the patients file folder.

We find that the FotoFinder provides us with the cutting edge imaging solution for consistent before and after photo documentation of virtually any aesthetic procedure from head to toe consistently and has provided an excellent educational and selling tool. We are finally able to accurately reproduce and document the effectiveness of treatment which leads to patient satisfaction.

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    Occupation: Physician Assistant/Nurse Practitioner
    Setting: Miami & Upland, Calif.
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